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19 December 2014
 
Consultancy Africa Intelligence (CAI) is a South African-based research and strategy firm with a focus on social, health, political and economic trends and developments in Africa. CAI releases a wide range of African-focused discussion papers on a regular basis, produces various fortnightly and monthly subscription-based reports, and offers clients cutting-edge tailored research services to meet all African-related intelligence needs. For more information, see http://www.consultancyafrica.com
 
 
   
 
 
Article by: Consultancy Africa Intelligence CAI
 
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Prison populations worldwide tend to have much higher HIV & AIDS prevalence rates than the general population – for many complex and interrelated reasons. In particular, this is a result of limited access to prevention methods despite high rates of injecting-drug use and unprotected sex.(2)(3)(4) This is a result of prisoners being ‘left-out’ when it comes to effective HIV & AIDS interventions. However, prisoners do not remain within the confines of a prison. The majority will return to their families and communities in the general population, many within less than a year. Thus, high rates of HIV infection within prisons are a cause for public concern when it comes to the risk of HIV & AIDS transmission in the general population.(5)(6)

This paper focuses on South Africa, a country that has seen significant advances in infrastructure and interventions for HIV & AIDS prevention, treatment and care in the general population. However, this has not been matched in prison contexts and there remain a number of challenges in implementing effective interventions in South African prisons. This paper aims to discuss these barriers in an effort to highlight what changes need to be made in order to provide prisoners with comprehensive HIV & AIDS packages.(7)

Prisoners at risk

HIV prevalence in South African prisons is estimated at 40-45%.(8)(9)(10) This is more than double the current prevalence in adults aged 15-49 in South Africa, estimated at 16.9%.(11)(12) Although the predominant demographic of South African prisoners (young black or coloured men aged 18-35)(13) are at high-risk for HIV before they enter prisons, the much higher prevalence and incidence rates within prisons are largely attributed to individuals engaging in high-risk behaviour with little or no protection. High-risk behaviour includes anal intercourse, sex with multiple partners and sexual assault, as well as tattooing and self-mutilation.(14)(15) Injecting-drug use (IDU) is not as common in South African prisons as it is in many other parts of the world (generally those with concentrated epidemics).(16) Despite these risks, prisoners generally have little access to prevention methods such as sterilised tattooing equipment, condoms, lubricants or even simply information and education about ways to protect oneself from contracting the virus.(17)(18)(19)(20)

It is vital that prisoners have access to public health interventions equivalent to those provided outside the prison walls.(21)(22)(23) High rates of infection are not contained within these facilities. This is particularly salient when it comes to transient prison populations. In South Africa, over 40% of South African prisoners are sentenced for less than a year,(24) whilst thousands of others that are in custody awaiting trial will be released after a few weeks or months, or transferred to another facility.(25)(26) Thus, interventions in prisons require partnership, cooperation and coordination with HIV initiatives in the general population in order to combat infection rates in South Africa at large.(27)

Challenges for prevention

Prevention is vital in a prison setting, not least because it is more cost-effective to invest in prevention than in treatment of individuals already infected with HIV.(28) Prevention strategies in prisons include availability of and access to sterilised tattooing equipment, disinfectants, condoms and lubricants, as well as information, education and counselling.(29)(30)

Prisons provide an ideal opportunity (in terms of access and time) to promote behaviour change, knowledge and awareness about HIV, particularly considering that those entering the prison are at high-risk for HIV in the general population as well.(31) However, prevention strategies have been met with a number of challenges.

The availability and accessibility of sterile equipment, condoms and lubricants is often seen to go against prison policies, which in many cases, ban drugs or sex of any description.(32) In South Africa, there are arguments that providing disinfectant or other sterilising materials to prisoners would result in these being used as weapons, or that providing condoms is futile because most sex is coercive.(33) This is despite evidence to the contrary.

Although it is currently South African policy to distribute condoms in prisons, the condoms available for distribution are designed for heterosexual sex. Furthermore, no lubricants are available. Thus, it is an unacceptable prevention method in a prison environment where anal sex predominates. Furthermore, condoms are only available from trained AIDS counsellors or from prison officials.(34)(35) This is a vastly different scenario to the availability of condoms in South Africa’s general population.

Requesting condoms from a prison official can lead to embarrassment or even fear of violence or coercion (particularly in settings where men who have sex with men (MSM) are highly stigmatised).(36) A lack of acceptance around condom distribution among prison officials can lead to secrecy among prisoners around their sexual practices, which will inevitably result in higher rates of unprotected sex.(37)(38) Thus, distribution of condoms is highly dependent on changing the attitudes of prison officials, as well as providing new ways in which prisoners can access suitable condoms more discreetly.(39)(40)

This leads to the challenge of implementing information, education and counselling (IEC) as a prevention mechanism in prison settings. IEC involves providing individuals or groups with information about risky behaviour and routes of HIV transmission, and effective ways to reduce one’s risk of contracting the virus.(41) However, effective IEC in prisons is hampered by the occasional inability of community-based organisations (CBOs) or others to gain access to prison populations in order to deliver these types of interventions. This is due to lengthy or restrictive security procedures, but more often because of negative stereotyping by prison officials.(42) As was mentioned above with relation to the distribution of prevention methods, prison officials’ attitudes are often at fault, and play a huge role in the effectiveness of prison programmes.(43) Thus, it is important that HIV prevention strategies in prisons are also aimed at providing effective IEC that will help these officials to alter their views and/or actions.

While there is a need for prison populations to receive prevention efforts comparable to that of the general population, it is worth noting that the prison environment does pose some unique challenges to prevention efforts. Prisoners are generally suspicious of ‘official’ programmes, and this can undermine interventions that have been successful in the general population.(44) Furthermore, prison populations cannot be viewed as a homogeneous group. It is a melting pot of, for instance, cultures, languages, sexual orientations and religions.(45) Thus, IEC needs to be tailored to suit the realities of a variety of different people, particularly where the focus is not only on behaviour change and awareness in a prison context, but also the context that these people will find themselves in once they are released back into society.(46)

Challenges for treatment and care

The treatment and care of those living with HIV & AIDS should be equivalent to the treatment and care available for the general population.(47) Comprehensive care should include the prevention and treatment of other sexually transmitted infections (STIs), tuberculosis (TB) and other opportunistic infections, as well as palliative care equivalent to that available to the general population.(48) For women, it should include care for HIV positive infants, as well as reproductive health services for women.(49)(50) Theoretically, prisons are an ideal setting for treatment adherence because patients are far less likely to be lost to follow-up (if at all).(51) However, there are many barriers to overcome if treatment and care is to be effective in a prison context.

At an organisational level, the HIV pandemic has resulted in prison healthcare facilities having to treat and care for many more chronically ill patients than was intended for these facilities.(52) Prison health facilities are not designed to cope with these numbers of HIV infections(53) and prison staff are overburdened. As a result, prisoners may not receive the treatment and care to which they should be entitled.(54)

A potential solution is the transfer of critically ill patients to public health facilities.(55) However, the scale of the epidemic in South Africa has made the hospitals overcrowded with patients suffering from HIV & AIDS, not to mention the lack of resources facing many public health facilities in the country. There needs to be a push to find practical solutions for the prison context to deal with high numbers of HIV-infected prisoners. This again highlights the importance of a comprehensive package that targets prevention, treatment and care in prison facilities.

Another barrier to effective implementation of treatment and care is the problem that occurs when prisoners are released from detention or are transferred to another facility.(56) It is important that there is effective linkage with community-based health programmes and facilities or healthcare in other prison facilities so that inmates are able to maintain their treatment adherence and receive adequate care when they are transferred or released.(57) However, it should be noted that this requires high levels of coordination and resources and this may overburden staff, resulting in inefficient referrals or follow-ups that hinder the quality of treatment that prisoners receive.(58)

For many prisoners who are released from prison, issues such as finding housing, being reunited with their families and finding employment are much more pressing than finding ways to continue treatment.(59) Treatment and care linkage programmes need to be delivered in a way that targets individuals’ specific needs, and provides solutions for adherence to treatment and accessing care in conjunction with the other issues facing the prisoner.(60)

Confidentiality is another challenge in prison systems. Prisoners who know their status and have access to ARVs may be discouraged from taking the medication for fear of social isolation or abuse. Concealing one’s medication from fellow prisoners or prison officials is difficult, and made even more difficult when prisons are overcrowded.(61)(62) In South Africa, prison occupation has been recorded as high as 161%.(63)

Other challenges for HIV prevention, treatment and care

Prison conditions such as overcrowding and poor nutrition are major barriers to the success of HIV programmes.(64) Poor nutrition, particularly a lack of fresh fruit and vegetables, affects all prisoners, but exacerbates the problem for those living with HIV who need to maintain their health.(65) Poor nutrition, coupled with inadequate natural lighting, ventilation, harsh weather, poor personal hygiene and inadequate medical services increases the risk of HIV infection as well as HIV-related mortality, and complicates the implementation of HIV interventions in prisons.(66) These poor conditions can also indirectly contribute to increased risk of HIV infection – for example, an increased rate of violence is associated with overcrowded prisons.(67) Thus, efforts to reduce HIV in prisons should be part of a broader effort to address sub-standard prison conditions.(68)

Another major barrier to comprehensive HIV & AIDS packages in South African prisons is inadequate research and surveillance. There has been little research on prevalence and programme effectiveness in these contexts.(69)(70) It is absolutely vital that prison health interventions and infrastructure be based on best practice and good evidence, rather than being a result of public opinion or political commitment.(71)

Conclusion

HIV is not only affecting populations in general society, but is also a seemingly uncontrollable epidemic within prison walls. This paper has highlighted a number of barriers that hinder the application of effective HIV prevention, treatment and care in this context, and the impact that this has not only on the health of prisoners, but on that of the general population as well. It is vital that funding be allocated to HIV interventions in prisons, in order for a strong evidence base to be created for the implementation of these programmes, which will provide prisoners with the best healthcare possible. The provision of programmes must not, however, be viewed in isolation from broader healthcare initiatives or improving prison conditions in general. HIV prevention, treatment and care cannot exist in a vacuum, separate from a range of issues affecting individual prisoners, both within the prison and on release.

HIV is but one issue affecting prison populations in South Africa. Although this paper has highlighted the challenges facing HIV prevention, treatment and care specifically, there are many other complex and interrelated factors that are affecting prisoners’ health. This includes, for instance, tuberculosis and STIs, which are epidemics in their own right, but have a significant impact on HIV transmission as well. Thus, an inclusive approach to healthcare for prisoners is essential in order to address a range of issues that affect individuals on a personal as well as on a wider contextual level.

NOTES:

(1) Contact Robyn Cox through Consultancy Africa Intelligence’s HIV & AIDS Unit (hivaids@consultancyafrica.com)
(2) Ibid.
(3) Elliott, R. 2007. Deadly disregard: Government refusal to implement evidence-based measures to prevent HIV and hepatits C virus infections in prisons. Canadian Medical Association Journal, 177, 262-264.
(4) Goyer, K. C. & Gow, J. 2002. HIV/AIDS policies, practices and conditions in South African prisons: Criticisms and alternatives; Towards a research agenda. African Journal of AIDS Research, 1, 69-74.
(5) Elliott, R. 2007. Deadly disregard: Government refusal to implement evidence-based measures to prevent HIV and hepatits C virus infections in prisons. Canadian Medical Association Journal, 177, 262-264.
(6) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(7) Ibid.
(8) WHO, UNODC, UNAIDS. 2007. Effectiveness of interventions to address HIV in prisons. Evidence for Action Technical Paper. Geneva.
(9) UNODC, UNAIDS, World Bank. 2007. HIV and Prisons in sub-Saharan Africa: Opportunities for Action.
(10) Dolan, K., Kite, B., Black, E., Aceijas, C., Stimson, G. 2007. HIV in prison in low-income and middle-income countries. Lancet Infectious Diseases, 7: 32-41.
(11) Human Sciences Research Council, Medical Research Council, Cadre, NICB. 2009. South African National HIV Prevalence, Incidence, Behaviour and communication Survey, 2008. HSRC Press: Cape Town.
(12) UNAIDS, WHO. 2009. AIDS Epidemic Update. Geneva.
(13) Goyer, K. C. 2003. HIV/AIDS in prisons: Policies, problems and potential. Institute for Security Studies.
(14) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(15) Wilson, D., Ford, N., Ngammee, V., Chua, A. & Kyaw, M. 2007. HIV prevention, care and treatment in two prisons in Thailand. PLoS Medicine, 4, e204.
(16) Dolan, K., Kite, B., Black, E., Aceijas, C., Stimson, G. 2007. HIV in prison in low-income and middle-income countries. Lancet Infectious Diseases, 7: 32-41.
(17) Jurgens, R., Ball, A. & Verster, A. 2009. Interventions to reduce HIV transmission related to injecting drug use in prison. The Lancet Infectious Diseases, 9, 57-66.
(18) Braithwaite, R. L. & Arriola, K. 2003. Male prisoners and HIV prevention: a call for action ignored. American Journal of Public Health, 93, 759-763.
(19) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(20) Wilson, D., Ford, N., Ngammee, V., Chua, A. & Kyaw, M. 2007. HIV prevention, care and treatment in two prisons in Thailand. PLoS Medicine, 4, e204.
(21) UNAIDS. 1999. WHO Guidelines on HIV infection and AIDS in prisons. Geneva
(22) OHCHR, UNAIDS. 2006. International Guidelines on HIV/AIDS and Human Rights. Geneva
(23) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(24) Goyer, K. C. 2003. HIV/AIDS in prisons: policies, problems and potential. Institute for Security Studies.
(25) Ibid.
(26) Schalkwyk, A. 2005. Killer Corrections: AIDS in South African Prisons. Harvard International Review.
(27) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(28) Elliott, R. 2007. Deadly disregard: Government refusal to implement evidence-based measures to prevent HIV and hepatits C virus infections in prisons. Canadian Medical Association Journal, 177, 262-264.
(29) Ibid.
(30) Goyer, K. C. & Gow, J. 2002. HIV/AIDS policies, practices and conditions in South African prisons: criticisms and alternatives: towards a research agenda. African Journal of AIDS Research, 1, 69-74.
(31) Ibid.
(32) Ibid.
(33) Goyer, K. C. & Gow, J. 2002. HIV/AIDS policies, practices and conditions in South African prisons: criticisms and alternatives: towards a research agenda. African Journal of AIDS Research, 1, 69-74.
(34) Goyer, K. C. & Gow, J. 2002. Alternatives to current HIV/AIDS policies and practices in South African prisons. Journal of Public Health Policy, 23 (3): 307-23.
(35) Schalkwyk, A. 2005. Killer Corrections: AIDS in South African Prisons. Harvard International Review.
(36) Goyer, K. C. & Gow, J. 2002. HIV/AIDS policies, practices and conditions in South African prisons: criticisms and alternatives: towards a research agenda. African Journal of AIDS Research, 1, 69-74.
(37) Wilson, D., Ford, N., Ngammee, V., Chua, A. & Kyaw, M. 2007. HIV prevention, care and treatment in two prisons in Thailand. PLoS Medicine, 4, e204.
(38) Goyer, K. C. & Gow, J. 2002. Alternatives to current HIV/AIDS policies and practices in South African prisons. Journal of Public Health Policy, 23 (3): 307-23.
(39) Wilson, D., Ford, N., Ngammee, V., Chua, A. & Kyaw, M. 2007. HIV prevention, care and treatment in two prisons in Thailand. PLoS Medicine, 4, e204.
(40) Goyer, K. C. 2003. HIV/AIDS in prisons: policies, problems and potential. Institute for Security Studies.
(41) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(42) Braithwaite, R. L. & Arriola, K. R. 2003. Male Prisoners and HIV prevention: a call for action ignored. American Journal of Public health, 93, 759-763.
(43) Wilson, D., Ford, N., Ngammee, V., Chua, A. & Kyaw, M. 2007. HIV prevention, care and treatment in two prisons in Thailand. PLoS Medicine, 4, e204.
(44) Goyer, K. C. & Gow, J. 2002. Alternatives to current HIV/AIDS policies and practices in South African prisons. Journal of Public Health Policy, 23 (3): 307-23.
(45) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(46) Braithwaite, R. L. & Arriola, K. R. 2003. Male Prisoners and HIV prevention: a call for action ignored. American Journal of Public health, 93, 759-763.
(47) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(48) Ibid.
(49) Note: although research on HIV/AIDS in prisons is sparse in South Africa, male prisoners receive the most attention. The issues facing female prisoners are severely underrepresented in the literature.
(50) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(51) Wilson, D., Ford, N., Ngammee, V., Chua, A. & Kyaw, M. 2007. HIV prevention, care and treatment in two prisons in Thailand. PLoS Medicine, 4, e204.
(52) Goyer, K. C. & Gow, J. 2002. HIV/AIDS policies, practices and conditions in South African prisons: criticisms and alternatives: towards a research agenda. African Journal of AIDS Research, 1, 69-74.
(53) Goyer, K. C. 2003. HIV/AIDS in prisons: policies, problems and potential. Institute for Security Studies.
(54) Spaulding, A. C., Arriola, K. R. J., Ramos, K. L., Hammett, T., Kennedy, S., Nrton, G. & Tinsley, M. 2007. Enhancing linkages to HIV primary care in jail settings: Report on a consultants’ meeting. Journal of Correctional Health Care, 13, 93-128.
(55) Goyer, K. C. & Gow, J. 2002. HIV/AIDS policies, practices and conditions in South African prisons: criticisms and alternatives: towards a research agenda. African Journal of AIDS Research, 1, 69-74.
(56) Wilson, D., Ford, N., Ngammee, V., Chua, A. & Kyaw, M. 2007. HIV prevention, care and treatment in two prisons in Thailand. PLoS Medicine, 4, e204.
(57) Spaulding, A. C., Arriola, K. R. J., Ramos, K. L., Hammett, T., Kennedy, S., Nrton, G. & Tinsley, M. 2007. Enhancing linkages to HIV primary care in jail settings: Report on a consultants’ meeting. Journal of Correctional Health Care, 13, 93-128.
(58) Ibid.
(59) Spaulding, A. C., Arriola, K. R. J., Ramos, K. L., Hammett, T., Kennedy, S., Nrton, G. & Tinsley, M. 2007. Enhancing linkages to HIV primary care in jail settings: Report on a consultants’ meeting. Journal of Correctional Health Care, 13, 93-128.
(60) Ibid.
(61) Braithwaite, R. L. & Arriola, K. R. 2003. Male Prisoners and HIV prevention: a call for action ignored. American Journal of Public health, 93, 759-763.
(62) Wilson, D., Ford, N., Ngammee, V., Chua, A. & Kyaw, M. 2007. HIV prevention, care and treatment in two prisons in Thailand. PLoS Medicine, 4, e204.
(63) Steinberg, J. 2005. Prison Overcrowding and the Constitutional Right to Adequate Accommodation in South Africa. Centre for the Study of Violence and Reconciliation. http://www.csvr.org.za.
(64) Goyer, K. C. & Gow, J. 2002. HIV/AIDS policies, practices and conditions in South African prisons: criticisms and alternatives: towards a research agenda. African Journal of AIDS Research, 1, 69-74.
(65) Ibid.
(66) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(67) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.
(68) Ibid.
(69) Goyer, K. C. & Gow, J. 2002. HIV/AIDS policies, practices and conditions in South African prisons: criticisms and alternatives: towards a research agenda. African Journal of AIDS Research, 1, 69-74.
(70) Goyer, K. C. & Gow, J. 2002. Alternatives to current HIV/AIDSHIV & AIDS policies and practices in South African prisons. Journal of Public Health Policy, 23 (3): 307-23.
(71) UNODC, WHO, UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support: A Framework for an Effective National Response. Vienna.

Written by Robyn Cox (1)

Edited by: Consultancy Africa Intelligence CAI
 
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